HomeMy WebLinkAboutMiscellaneous - 27 DAVIS STREET 4/30/2018-V
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CO Town of North Andover, MA A
21027
*Plumbing Permit - Renovation/Afteration/Addition Fixtures and/or Appliances (Commercial or Residential)
rIMELINE
Submission received
Plumbing Review
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Tuesday, Aug 02, 2016 08:16 AM
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27 DAVIS STREET, NORTH ANDOVER,
MA
0—
DRISCOLL JAMES E
Attachments
-OTU80JI001 F_Tue-Aug-02.20I6-I2:l6:.POF
IT f6 1:16 AM C3
St�ens Memorial
Library
Richard Colmer
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27 DAVIS STREET, NORTH ANDOVER,
MA
0—
DRISCOLL JAMES E
Attachments
-OTU80JI001 F_Tue-Aug-02.20I6-I2:l6:.POF
IT f6 1:16 AM C3
13
V�-P-*#210A-Y-P X"
Town of North Andover, VIA Ck S�ccfl
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21026
*Gas Permit - Renovation/Alteration/Addition (Commercial or Residential NOT in conjunction with a Building Permit)
TIMEL INE
Submission received
---- -- -------------
GGas Permit Review
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Tuesday, Aug 02, 2016 08:13 AM
-1\ Your request is in progress
We'll let you know of any updates via email. Feel freetocheckthe
'tatusatanytime bycoming backtothispage.
Ste�ens Memorial
Library 'OT�"
Richard Colmer
Attachments
k; � , ,
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27 DAVIS STREET, NORTH ANDOVER,
MA
G—r
DRISCOLL JAMES E
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1:13AM
8"16
The Commonwealth ofMassqphusefts
Department ofIndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.govIdia
Workers' Compensation insurance Affidavit: BuRders/Contractors/Electricians/Plixmbers.
TO BE' MED WITH TBE PERMTTING AUTHORITY-
Namo (Business/orgm&-aflon/ludividual):
kA.dd,r.css: L4
tatc/zip:
Areyou an
�11
lav
Checki�e ppirlopriatie, box:
Phone #:
IT11amaemployarvAth —,. ! employees (full and/or part-time).*
am a sole proprietor�or partnership and have no employees wOrkkg for me in
capacity. [No woikers'comp. insurance requiredj
3 -FJ I am a homeowner doing all work myself, [No workers' comp -insurance required.] t
4. rJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
pr6Vrictors with no e4loyees.
5. F1 I am a general contractor and I have hired the sub -contractors listed on the, attached sheet
Theic s�b-contractor's �a�; ��ploye�s anih'ave workers' con�p. insurance.;
6.E] We are a c orp oration and its 9 f Ei c ers have exercis e d their right of exempti o n p ar MGL c.
- .. — ", j�, .
152, § 1(4). an4 wp ha�p .4q.e oy�es. [No workers' comp. insurance required.]
Type of project (T�quirtd)-.
7.- F1 Now constraction
8. El Remodelidg
El Demolition
10 FJ Buil(�ing addition
II.E] Electrical repairs oradditions
I plumbing repairs or add itions
1j.-DR66fiepairs
14. F1 Othbr
*Any applicantthat checics b6x 41 mu'st alsoM out the section below showing theirworIcers'compensationpolicy information -
T Homeowners -who subnjit tl* af�dayit indicating they are doing all work and then hire outside contractors must submit a now affidavil indicating such.
tContractors jthat check this box must,attached an additional sheet showing th� name of the sub -contractors and state whether or not those entities have
employees. - If the sub-c6A�L6s ta����pI6�e�es,'Iey' must provide their workers' comp. policy number.
lain an eihployerthat isprov�diizgwork�rsl compensation insuranceformy empl6ees.' Belo* is thepolley andjob site
information.
Insurance Company
Policy# or S elf -ins. Lic.
Expiration Date:
Y,, �ob Site Address:- A ,/,x City/State/Zip:
ach a copy of the workers compep�ation policy declaration page (showing the policy number and expiration date).
Failure to s-ecure cov6raga as required under MGrL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year finprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the office offhvestigati6ns of the DIA for insurance
coverage verifloation.
do hereby Ncif
7 1, ' of ly
d enaties perju that the informatlonprovided above is true and correct.
Official use only. Do not vrite in this area, to he completed by city or town officiaL
City or Town:
PermitiLicense #
Issuing Authority (circle one): i
1. Board of Health 2. Building Department I City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: — Phone #:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for thek pi�iplo6ye�s.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contrabt R'hire,
express or implied, oral or written."
An employer is defined as "an individual, partnersWp, association, corporation or other legal entity, *
or any two or more
of the foregoing engaged in ajoint enf6rprise, and including the legal representatives of a deceased employer, or the
receiver -or tru�tde of an individual, partnership, association or other legal entity, employing empl6�ees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who lias not produced acceptable evidence of compliance with the insurance coverage required.'.'
Additionally, MGL chapter 152, §25C(7) states "Neither the commoaw-ealth nor any of its political subdivisions shall -
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
�lea-se fill -out -the workers' compensation affidavit 6ompletely, by cheoking�ffi6boxes that apply to your situation and, if
necessary, supply sub-'contractoi(s) name(s), address(es) and -phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (I LQ or Limited Liability Partnerships (LLP) with no employ9es -other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC'or LLP does have
employees, apolicyisrequired. 1�e advised that this affidavit maybe submitted to the Depailment of - Ifidustrial
Accidents fb� ccaifirmationof insurance coverage. Also be sure to sign and date the aifidavit. Theaffida-Vitshowd
be returned to the city.or town that the application for the permit or license is bein'g requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you'are r�qa'jred to obtain a w.6rkers'
compensatioA �olicy, please call the Department. at the number listed below. Self-ib:sur6d companies sh.ould'enter their
self-insuraii�a license number on the appropriate line.
City or Town Officials
Please ba sure that the affidavit is complete and printed legibly. The Department hau provided a space. at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as axeference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped ormarked by the city or townmay be proi�ide_dto ihe
applicant as proof that a valid affidavit is on file for future permits or licenses. A now affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or pemait to bum leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department.of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NMSSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Nonni Am ovFR Bun. DiNG DEP-ARTMENT
1600 Osgood Street
v v %L'
Tel: 97.9-698-954:5
Fax: 979-688-9542
DATE:
NAME Ayn
ADDREM.
ZONING D-19TWIC"21'
TYM OFM8108
BUI[LDING LAYOUT PROVIDED: YES
-AMAE, AHUR PARKWG SPACM:
ZONINGBYLAWUNACTE:
JWSJ�MSS IFOPM POP, TOWN CLBRX
2.49 FfbweOccupa:Ucn(19S9J32)
An accesswy usG conducted wilhin a dweffig by a re��dqqt Jhq red
p flps k the, dwelft as is Principal
I os . o c ao
gpup es Hmoo cupfins shall
'�ificlifdq, - bft
RoOhnited to the fbllov�ng uses., personal services such a.- Runishcd ky an artist or instmotor,
but not occupation involved with motor vohicb �qpairq., bea�4,,pWoxs, at*ml kemels., ov tho conduct of
reftilbusihoss, orthonmufad"g o�goods, WhIchimpacts flibresidmflaInatao offhoiielghborhood,
4� For DRO of a dWONing in PY residoaf M distri d or MdU-hmffy distdct for a Jaoma occupdfior4 thG
following condif ions shall apply.
a. Not more ffim a ToW of fluep, (3) ppop
�jo may �q. q 'on, wo of
Wpjgyq. jkq!pq occupati
whom shall bolh�-owior IDB'hd_M��.dbrbn'pation atidreAfti-ft- -said dlkolffig,
b. lhousaig ca-aietl on stdotlyv&hin to principal bdft;
0. Thom " bo no oxte:dor aftoratiaas, accesgay buildings, or &play -which aro -not cust=W
with xosidmtial buildings, .
d. Not more, Vm fwm-�flvo (25) prrcmt of ffio e�dsfhg gross rqoor arm oftho diwag Upit.
so used, not to exceed one thowand (1000) square Rd, is devoted to'such uso. In,
conneGdollwifh
such USO, thuG is 'to bo kept no stock in t-adq, commoMes, or pxoducts which occapy quo
bkvotdthesowts",
0. nere, will bo no display ofgo&Ig or waxes -Osiblo fiom tha streq,
Tfio, bdft or Promises mcupied shall notbo vamdeared objectionablio or detrimmW to tho
xoddenVal character of tho nolihboThood. dno to tho qdonor appoaxanw, odssioao� odor,
gas., Fmoko, dust, noisq., distuAanco� or ha any ofhtr way becomc) objoctionable, or
d&hwtal to any residentiall use, vvithin ffie, ndA o±God;
9. Av such bullft shall moludono featuxes of design— Rot customaq in bulldinpg-fianesidential
A AYPQB D
11
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniforin throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit applicati o*n. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall -be limited as to the time of ongoing construction activity, and may be.deemed -by the Jnspector-of-W-ires abandoned.and.invalidiflie—
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be perraitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 20 10 and extended by Sections 74 and 75 of Chapter 23 8 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
puipose by establishing an automatic four-year extension to certain permits and licenses conce ngthe se or development of real proper Wi
-wise applicable expiration date, any permit or approval that was
limited exceptions, the Act automatically extends, for four years beyond its other Mi 11 ty th
"in effect or existence`4 during the qualifying period beginning on August 15, 2008 and extending'through August 15, 2012.
X_Rule 8 — PermitYDate Closed:--(-�Xj 1, Note: Reapply for new perm
0 Permit Extension Act — Permit/Date Closed:
Date ...... �-. —.. A. —.. � Z—.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
0. C?�A t
This certifies that ........... P . .... ............. P ..................................
has permission to perform ........ ............ ..................
wiring in the building of ........ .............................................
............................................................. . �,orlffih AAndovei, ass.
W
Fee..I�� Lic. No..�A� ............
t:'=L SP
0
Check # 7.
.10643
'L Official Use Only
\ - Commonwealth of Massachusetts
it No.
Department of Fire Services Perin
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] Qeaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLF-4SE PRflVT 1N INK OR TYPEALL INFORAM TION) Date:- 2/� 1A
City or Town of. NORTH ANDOVER To the Inspe r of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) a _2 nCi �S_7L
Owner or Tenant / M t
Owner's Address "X - r Y) e -
Is this permit in conjunction with a building permit? Yes
Purpose of Building 61,n9�e rarn,
I
Telephone No.
No [:1 (Check Appropriate Box)
Utility Authorization No.
Existing Service Amps Volts OverheadEl UndgrdE1 No. of Meters
New Service Amps volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
I -- .7 r
No. of Recessed Luminaires
LL= 1-- -A
No. of Ceil.-Susp. (Paddle) Fans
c�(-f u US
N"'o" o52 uY "su J;N—tal J r#'Ir
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators K -VA
No. of Luminaires
Above [:] In.- E]
Swimming Pool
IN 0. of Emergency Lighting
grnd. arnd.
BaftenLlQnits,.
No. of Receptacle Outlets S7
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
I Number.1-Tons
........... -*1
.... ........
IKW
N—o.of Self -Contained -
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Areia Heating I(W
LocalEl Mimic" EJ Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:T,
No. of Wa
No. of No. of
No. of Devices or Equivalent
Heaters KW
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications WiKing:
No. of Devices or Equivalent
OTHER:
,%uacn aaamonai aerait y aesirea, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: OL000 (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE El BOND El OTHER El (Specify:)
I certtfy, under ihwalns andpenalties ofperjury, that the information on this application is true and compleie.
FIRMNAME: VJ�C-Cf-,&, E�eC+r:C- LIC. NO.:Do s) -o A
i�-- pt,CCC6 Signature
Licensee:r _S1 'r
af applicable t r 'fi'xeMpt 'in the license nunibe6hne.),,�,
Address: M V- V f::ii Bus. Tel. No.lcl D I a U 76ol
Y'Y"\ Q �2-- Alt. Tel. No.: 10
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one)EI owner El owner's agent.
Owner/Agent
Signature Telephone No. EE.
ELECTRICAL PERMIT NO. INSPECTIONREPORT:
ELECTRICALINSPECTOP,
I. POVGA.).NSPyCTfON; " , , -
asse - Nalled—f Re-impectioureqidrecT($50.()O)-f
FPassed
�nspecctors clomlm�emts:
A
frr.qnP.rfA-r-Q Signature -no
knUs) Date
2. JUMAL IMPACTION,
P as F7sea —�f Failed Reiuspection required ($50.00) -
f spe,
_tors e
-uspectors' commen
(fAs&ctors' Signature - no initials) Date
M3. UMER GROIM INSPFCTION.
3' ER C
hassed—f I
Inspectors, c
Inspectors' comments;
(Tnsn ctors" Signature - no initials) Date
4. INSPECTION—SERVICE:
DATI & CALLER D NATIONAL GIR DO NAYA:
Passed—f ) Failed — f 1 00) -
Inspectbrs, commenis:
(Inspectors' Sigu�ture, - no initials) Date
5. INSPECTION - OTRER:'
Passed— [ I Failed 'Re -inspection required ($50.00) - f
Inspectors, con�ments:
OCUSP ectors, Signature -no furtials) Date
D 0 OR TAGS ARE TO BE MUD OIDT AND LEFT ONSITE IU THE APXA TO BE INSPE . CTED 18 -NOT
ACCESSIBLE AND ARE-INSFECTION OF$50.00 18 TO 13)9 CHARGED.
The Commonwealth ofMassachusetts
D2 Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
W www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
a
Are you an employer? Check the appropriate box:
LEI I am a employer with
4. El I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
2. El I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3.0 1 am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] f
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. New construction
7. Remodeling
8. E] Demolition
9. F] Building addition
10. F1 Electrical repairs or additions
11. F1 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other
*Any applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information.
1"Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that is providing workers' compensation insurancefor my employees. Below isthepolicy andjob site
information.
Insurance Company
, W Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address: Citv/State/Zit):
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct.
Simature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer'is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. 'the affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Sho ' uld you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for ftiture permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or -permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
9276
Date.
\0 TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that
has permission to perform
plumbing in the buildings Of ....
..............................
at ... �.7 Adl , N And
........... Mass.
3-�
Fee .... 7�� . Lic. No .......... . f ............. ...
Check # ZU 7 ? PLUMBING I SPECTOR
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
wyl,�- Atdaileil'- IMA DATEJ j-,�4-jP—j,PERM1T#
JOBSITE ADDRESS OWNER'S NAME]
OWNERADDRESSI S/PIUV-01 I TELlf 7T -c7 7j-`4—)4)�j FAX I
TYPE OR
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
NEW. RENOVATION: I 1?"�REPLACEMENT: PLANS SUBMITTED: YES NOI I
FIXTURES -1 FLOOR—
BSM
1
2
3
4
6
6
7
a
9
10
11
12
2
14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
I
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
TE:
DRINKING FOUNTAIN
- ,
FOOD DISPOSER
,
FLOORiAREADRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK L A 14, hd,,.f
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER I
-J ---1 - - - - - -
INSURANCE COVERAGE:
I have a ctirrent liabiliky nsurance policy or its substantial.equivalent which meets the requirements of MGI- Ch. 142. YES -NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGEBY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the'Insurance coverage requited by Chapter'1142 of tile
Massachusetts Getteral Laws, and that my signature on tifis perillit applicWt:1011 waives this requirenlerit.
SIONATURE OF OWNER OR AGENT CHECK ONEONLY: OWNER AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application atei true and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be' Ii %-A!W Plinent of the
�tovlsion
Massachusetts State Plumbing Code and Chapter 142 of the General Lavvs.
PLUMBER'S NAME C`4,4i'61 LICENSE # JM32ttf MUM I UKt:
I
MPI I JP I L�� CORPORATIONI III! 1PARTNERSHIPI ILLCI 1#1
COMPANY NAME! Ple-&&W64 1ADDRESS1 4 Zfmlir�k
,
CITY 1 10 k—/ STATE I V)� I ZIP 10 '? e-,- r I TEL
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-Policy.
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Affneltacopyipr(i Will C011111611
tb4ure- OVeflig-as req u !led un det &Woi-i �,�A O�Mbr,
..t- 152C611 lelld.tO file
IF1410 lip tq'V00.60 as %vel[ as civil
illaybefo 'rift
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or Ills umfice coverage ved fic lion.
0
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Cifj
6, Other
Colifutt
Camnwnwea(N .1 Ifla-ijaclLuieltj Ljsc Only
2,par1nwn1 I ji, Pern-lit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev. 11/991 (leave blank-)
APPLICATION FOR PE'-RMIT TO PERFORM ELECTRICAL WORK
All -,vurk to be pcolornied in ziccordancc with the Massachusetts Electrical Code (MEC), 527 CNIR 12.00
(PLEASE PRIIVTIiV INK OR TYPEAL� hYFORMA770N Date:
City orl-oiyll of:
By this appli i To the��ns�pecioir of JP'i1-0,s:
,cation tile undersigned gives notice ol-bis or her —'ntention 10 pCrfOTni the electrical work described below.
Locatioij (Street &- Null)l) 7 /Oat:,/,,�S
er) GIL
Owner or Tenant Ur� S,
Owner's Address -<a m e -
Is this perinit in c0lijuliction with a buildin- permiII? . Yes
I'll' -pose of Building `�',ns te- R-- �-' - t ) V c)w-e' k � c'-�
Existing Service
1:1 — Anips Volts
New Seri -ice —. Anips- Volts
Number of Feeders asid Anipacity
Location and Nature of Proposed Electrical Work:
- + r-\ �C'yh%
No 11
Telephone 1No.
(Check Appropriate Bo.x)
Utility Authori7ation No.
Overhead
El
Und-rd
1�
-1
E
-
No. of Meters
Overlicad
No. of Lighting Owlets
Undord
El
N (). or im eters:
e-1. i — 1 11
-P
6<
No. of Recessed Fixtul-es
;;;PCs 0" of "'clu'"Jiv"19
1a01e)'1aY be waired by the ln��Cctor orivies.
No. o�f
-.3
No. of Ceil.-Susp. (Paddle) Falls
Total
Tralisforniers
No. of Lighting Owlets
No. of Hot Tubs
1�f V '4'
Generators KVA
No. of Lighting Fixtures ls-
Above
Slyinimin.- Pool n-
�rn
9 III 1 10 Iting
Mid. g d.
Batte!:j'Units'
FIRE ALAMIS FANo- of Zones
No-ofReceptacleOutIels. 30
No. of Oil Burners
No. of Switches "It)
No. of Gas Burners
TNO- 01"Vetection and
Initiating Devices
No. of Ranues
No. of Air Corid. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat yu lip
Number
ITons
!To � �! �:; 1: 1 ��: ;:7 ��
11 � I''Cl I I Li ned
Totals-
Detection./Alerting Devices
No. of Dis-hiv.nsliers
Spncd,%ren Heating KW
Local El mull"Pal E] Other
Connection
No. of Dryers
Heating Appliances KW
Security Systeills-
.
-Devices
No. o Water
T<W
No. of IN 6. of—,
No. of or Equivalent
Heaters A
Signs Ballasts
Data Wiring:
No. of i3evices or Equivalent.
No. Hydroinassage Bathtubs No. of Alotors 'r—el—ec—on—imu- ri�jig
Total HP ilications Wi -
No. of Devices or Eguivaie nt
OTHER: I
ki 0 ty-rip -� rr.-, V -P tN'r-l-eC-k0C Q 1 C4
1,411ach additional detail if desired. or as required kv the Inspector of Wires . I
INSUP,00CE COVERAGE: Unless waived by The owner, no permit for the performance of electrical --ork may issue unless
the licensee provides proof of liability insurance including "Completed operation" coverage or its substa %N
ntial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issui,12 off -ice.
CHECK ONE: ICSURj%NCE IM BOND F
Estimated Value of Electrical Work:
0`11-11311 [1 (Specify:
. (When required by municipal policy.)
(Expiration Date)
Work (c, Start: hispecliolls to be requested in accordance -with MEC Rule 10, and upon completion.
I c(!"tifj', '1111lei- thepains nirdpei.ialties vfpeijur3-, that the information on thi5 application is true and coniplete.
F1101 NANIE: Ll C. N 0.:
Licensee: Signature LIC.NO.:-?,�02-1�
(If alyplicub -exempi " in the licen.ve number line.)
Address: I �-j , CC-ey �ZIIIZ) scc4s/3 rk,?III Bus. Tel. No.:nn 1 3-1 V
Alt. Tel. No.: W W-vLlz�-01
OWNER7S INSUR . ANCEWAIVER: I am aw-at-Filiat (fie License,- does not have the liability insurance covera.�e nomially
required by 13\ iny signatuic below, I hereby \vaivc this requirernent. I ani the (check onc) [] owilcr 0 owner's 31,eill
Owner/Agent
Signat ure" TIelephoile No. F-RMIT F- E- E: S
TOWN OF NORTH ANDOVER
YA
PERMIT FOR GAS INSTALLATION
This certifies that ......
has permission for gas installation ..... ...........
in the buildings of .............................
at ............ North Andover, Mass.
Fee. J/A Lic. N07r'�"'�4'
Check #
6
MASSACHUSEYIS UNIFORM APPLICATON FOR PERMI`r T`O DO GAS FrFrING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations
Owner's Name
New 13/ Renovation 1:1 Replacement 1:1
Plans Submitted
Pen -nit #
Amount$
(Print or type)
Name
FusinessTelephone
Name of Licensed Plumber or Gas Fitter
f Check one: Certificate Installing Company
,CAI Corp.
0 Partner.
e
INSURANCE COVERAGE Check one: No 1:3
I have a current liability Insurance policy or it's substantial equivalent. Yes 0
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 0 Other type of indemnity 0 Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this pennit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent 13
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with ail pertinent provisions of the Massach4ts(St e GA(C�d!)909,*ter 142 of the General Laws.
A � -A
VED (OFFICE USE ONLY)
Signature of Licensed Plumber Or G Fi er A
Plumber
0 Gas Fitter =icense Number
0 Master
r;�,�—eyman
1ST.- FLOOR
3RD.FLOOR
MAWA �18
7TH. FLOOR
(Print or type)
Name
FusinessTelephone
Name of Licensed Plumber or Gas Fitter
f Check one: Certificate Installing Company
,CAI Corp.
0 Partner.
e
INSURANCE COVERAGE Check one: No 1:3
I have a current liability Insurance policy or it's substantial equivalent. Yes 0
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 0 Other type of indemnity 0 Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this pennit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner 13 Agent 13
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with ail pertinent provisions of the Massach4ts(St e GA(C�d!)909,*ter 142 of the General Laws.
A � -A
VED (OFFICE USE ONLY)
Signature of Licensed Plumber Or G Fi er A
Plumber
0 Gas Fitter =icense Number
0 Master
r;�,�—eyman
4IFP
Date.
0q ORTh N, L/
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... e.. -v .... 0 ...... ......
has permission to perform ............. I ........
plumbing in the buildings of . . . . . . . . . . . . . . . . . .
. . . . . . . . . .
........ ........ Norlh Andover, Mass.
Fee. '17. . 4e Lic. NoF?i�)`*� .
Z...... .......
IN
Check 4 �PLB SPECTOR
6575
4
V
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
a4v"� �/' Date
Building Location Owners Name ('nA Or- "J"'Ca Permit #
Amount
Type of Occupancy
New Renovation Replacement 1:1 Plans Submitted Yes. No
FIXTURES
(Print or type)
Check one: Certificate
Installing Company Name
'
1-1 Corp.
r
Address / 14 M
0 Partner.
/V
ff g3
Business Telephone //5
/Y y 2
01 4 6 5-
[3--virnVC0.
Name of Licensed Plumber:
Cri tin
surance Coverage: Indicate the typorof insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity El Bond
Insurance Waiver: 1, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
I Signature Owner Agent
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and Accurate to the
best of my knowledge and that all plumbing work and installations perfpnCe"nder Issued for this application will be in
e s Sta P od nd e f the neral Laws.
compliance with all pertinent provisions of the MassachRqs
0 '/Z"Az�
By: Signature of Licensea FlumDer
Title Type of Plumbing License
City/Town 1.1cense lNumuer Master Journeyman
APPROVED (OFFICE USE ONLY
ABATEMENTCONNOL SMVICES 11C.
ENVI RON M ENTAUDEMOLITION CONTRACTORS
August 1, 2005
NORTH ANDOVER BOARD OF HEALTH
27 Charles Street
North Andover, MA. 01845
978-688-9540
DEAR SIR/MADAM
ENCLOSED PLEASE FIND A COPY OF NOTIFICATION SENT TO THE STATE
FOR AN ASBESTOS ABATEMENT PROJECT.
THE JOB WILL TAKE PLACE ON: Monday August 15, 2005
LOCATION: 27 Davis Rd. No. Andover, Ma.
ANY QUESTIONS CONCERNIG THIS MATTER SHOULD BE DIRECTED TO MY
ATTENTION.
SINCERLY,
FRANK BALOGH
PRESIDENT
129 NEWTON ROAD * PLAISTOW, NH 03865 - (603) 382-4035 - (603) 382-4036 - Toll Free (888) 870-9292 * Fax (603) 382-4037
Important
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
INSTRUCTIONS
1. All sections of this
form must be
completed in order
to comply with
DEP notification
requirements of 310
CMR 7.15
and the Division
of Occupational
Safety (DOS)
notification
requirements of 453
CIVIR 6.12
0
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0
LL
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Commonwealth of Massachusetts
Asbestos Notification Form ANF -001
A. Asbestos Abatement Description
a. Is this facility fee exempt - city, town, district, mun
residence of four units or less? R1 Yes [] No
b. Provide blanket decal number if applicable:
2. Facility Location:
F100020764
Decal Number
I I
Blanket Decal Number
IJACQUI DRISCOLL 1 127 DAVIS ROAD
a. Name of Facility b. Street Address
INORTH ANDOVER IMA 1 101845 F(978) 9-75-4419
c. City/Town d. State e. Zip Code f. Telephone Number
3. Worksite Location:
IBASEMENT AREA I :J
a. Building Name/Building Location b. Building # c. Wing d. Floor e. Room
4. Is the facility occupied? FZ] Yes F1 No
5. Asbestos Contractor
JACS ENVIRONMENTAL SERVICES
a. Name
FP—L-�'—Sirow— 1 103865 1
c. Cityrrown d. Zip Code
JAC000362
t. DOS License Number
6. IJOSE ALICEA
a. Name of On -Site SupervisoF/F-
[ENVIROTEST LAB., INC.
7. a. Name of Project Monitor
8. JENVIROTEST LAB., INC.
a. Name of Asbestos Analytical
9. [08/15/2005
a. Project Start Date (mmlddlyl
17-4
c. Work hours Mon -Fri.
10. a. What type of project is this?
E] Demolition E] Renovation
El Repair [Z] Other, please specify:
11 - a. Check abatement procedures:
M Glove bag
El Enclosure
Cleanup
Full containment
E] Encapsulation
0 Disposal only
F-1 Other, specify:
F129 NEWTON RD
b. Address
16 33824035
e. Telephone Number
g. Contract Type: [Z] Written E] Verbal
FREMOVAL
b. Describe
F -
b. Describe
12. Is the job being conducted: R] Indoors? El Outdoors?
0 anf001ap.doc - 10/M> Asbestos Notification Form - Page 1 of 3 0
Commonwealth of Massachusetts
Asbestos Notification Form ANF -001
A. Asbestos Abatement Description (cont.)
1100020764
Decal Number
13. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encaDsulated:
1132
a. Total pipes or ducts (linear tt) D. I ofal other surTaces (square tt)
c. Boiler, breaching, duct, tank
surface coatings
Lin. ft.
e. Corrugated or layered paper
Sq. ft.
pipe insulation
Lin. ft.
f. Trowel/Sprayer coatings
g. Spray -on fireproofing
Lin. ft.
h. Transite board, wall board
i. Cloths, woven fabrics
Lin. ft.
k. Thermal, solid core pipe
insulation
Lin. ft.
14. Describe the decontamination system(s) to be used:
IFULL CONTAINMENT
1. Specify
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (a):
IWET REMOVAL INTO 6 MIL ASBESTOS POLY LABELED BAGS I
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
I I
a. Name of DEP Official b. Title
c. Date (mm/dd/yyyy) of Authorization d. DEP Waiver#
e. Name of DOS Official 1. DOS Official Title
g. Date (mm/dd/yyyy) of Authorization h. DOS Waiver#
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? [] Yes [D No
B. Facility Description
1. Current or prior use of facility: IRESIDENCE
2. Is the facility owner -occupied residential with 4 units or less? R1 Yes El No
3. FJACQUI DRISCOLL I F27 DAVIS ROAD
a. Facility Owner Name b. Address
INORTH ANDOVER, MA. 101845 1978-975-4419
c. Cityjown d. Zip Code e. Telephone Nu
4. a. Name of Facility Owner's On -Site Manager b. On -Site Manag
F_ I I I I
c. City[Town d. Zip Code e. Telephone Nun
anf001 ap.doc - 10/02 Asbestos Notification Form - Pa 2 f 3 N
im
d. Insulating cement
Lin. ft.
Sq. ft.
f. Trowel/Sprayer coatings
Lin. ft.
Sq. ft.
h. Transite board, wall board
Lin. ft.
j. Other, please specify.
Lin. ft.
Sq. ft.
1PIPE
7
1. Specify
15. Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR
6.14(2) (a):
IWET REMOVAL INTO 6 MIL ASBESTOS POLY LABELED BAGS I
16. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
I I
a. Name of DEP Official b. Title
c. Date (mm/dd/yyyy) of Authorization d. DEP Waiver#
e. Name of DOS Official 1. DOS Official Title
g. Date (mm/dd/yyyy) of Authorization h. DOS Waiver#
17. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? [] Yes [D No
B. Facility Description
1. Current or prior use of facility: IRESIDENCE
2. Is the facility owner -occupied residential with 4 units or less? R1 Yes El No
3. FJACQUI DRISCOLL I F27 DAVIS ROAD
a. Facility Owner Name b. Address
INORTH ANDOVER, MA. 101845 1978-975-4419
c. Cityjown d. Zip Code e. Telephone Nu
4. a. Name of Facility Owner's On -Site Manager b. On -Site Manag
F_ I I I I
c. City[Town d. Zip Code e. Telephone Nun
anf001 ap.doc - 10/02 Asbestos Notification Form - Pa 2 f 3 N
im
Note: Transfer
Stations must
comply with the
Solid Waste
Division
Regulations 310
CMR 19.000
C0
��o
�O
0
LL
Z
Commonwealth of Massachusetts
Asbestos Notification Form ANF -001
B. Facility Description (cont.)
5. F-
a. Name of General Contractor
I I I
c. Citvrrown d. Zip Code
I I
f. Contractor's Worker's Comp. Insurer
6. What is the size of this facility?
F100020764
Decal Number
b. Address
I I
e. Telephone Number (area code and extension)
I i I
q. Poliev Numb r h. Exp. Date (mm/dd�MM)
I --] F
a. Square Feet b. Number of floors
C. Asbestos Transportation and Disposal
1. Transporter of asbestos -containing material from site to temporary storage site (if necessary):
JABATEMENT CONTROL SERVICES, IN—C-7-1
a. Name of Transporter
IPLAISTOW, NH.
c. City/Town d. Zip Code
2. Transporter of asbestos -containing waste material
ISERVICE TRANSPORT GROUP, INC
a. Name of Trans2orter
INEW CASTLE, DE.
3.
and Owner
I I
d. ZiD Code
4. A & L SALVAGE INC
11225 STATE ROUTE 45
c. Final Dispos2l Site Address
OH 144432
e. State f. Zip Code
D. Certification
The undersigned hereby states, under the
penalties of perjury, that he/she has read the
Commonwealth of Massachusetts regulations
for the Removal, Containment or
Encapsulation of Asbestos, 453 CIVIR 6.00 and
310 CM R 7.15, and that the information
contained in this notification is true and correct
to the best of his/her knowledge and belief.
N anf001ap.doc - 10/02
F129 NEWTON ROAD
b. Address
1(603) 3824035
e. Telephone Number
from removal/temporary site to final disposal site:
158 PYLES LANE
b. Address
1(877) 999-9559
e. Telephone Number
b. Address
IFRANK BALOGH
a. Name
b. Authorized Signature
1PRESIDENT
108/01/2005
c. PositionlTitle
d. Date (mm/dd/vvvy)
1(603) 382-4035 1
1A.C.S. INC.
e. Telephone Number
f. Representing
1129 NEWTON ROAD
g. Address
IPLAISTOW, NH.
Fo-3865—
h. City/Town
i. Zip Code
Asbestos Notification Form - Page 3 of 3 0
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
AcHUS
This certifies that . A!��,r
has permission for gas installation .... P 4W. .............
in the buildings of ..1k ie. .....................
at . '�"q ... 7,"� .......... North Andover, Mass.
117
Fee.34.�: Lic. No..
� A INSPECTOR
S'
Check#
5 r
20
MASSACHUSETTS UNEFORM APPUCATON FDR PERMIT To Do GAS MTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date CJ/22-/05
Building Locations 60 Deermeadow Rd Permit # 'r
residential Owrier'sNameSunit Mukherjee Amount S
New E6 Renovation n Replacement 1:1 Plans Submitted El
$36.00
U B - B A S E - M E N T
!AS EM ENT
ST.
ND.FLOOR
FLOOR
RDIFLOOR
TH-FLOOR
TH-FLOOR
TH.FLOOR
TH. FLOj-R—
STH. FLOOR
z
Lo
U
C en ri
(Print or type) Eastern Propane Gas Ch one: Certificate Installing company
Name ff Corp.
Address 131 Water St. Partner.
7
Business Telephone
��00
E;C
Finn/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check 22L
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No[3
Ifyou have checked Yes, please i dicate the type coverage by checking the appropriate box -
Liability insurance policy H Other type of indemnity ED Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application—waives this requirement.
Check one:
Signature of Owner Owner's Agent Owner Agent
i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stale Gas* Code and Cha ter 142 of the General Laws.
!City/To7,—n----
ROVED(OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber 777? ----2 <!�>
Gas Fitter License Number
Master
r7 Journeyman
Q
U
U
I=
0
1 1z
1> I -It
(Print or type) Eastern Propane Gas Ch one: Certificate Installing company
Name ff Corp.
Address 131 Water St. Partner.
7
Business Telephone
��00
E;C
Finn/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check 22L
I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No[3
Ifyou have checked Yes, please i dicate the type coverage by checking the appropriate box -
Liability insurance policy H Other type of indemnity ED Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application—waives this requirement.
Check one:
Signature of Owner Owner's Agent Owner Agent
i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stale Gas* Code and Cha ter 142 of the General Laws.
!City/To7,—n----
ROVED(OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber 777? ----2 <!�>
Gas Fitter License Number
Master
r7 Journeyman
'14
61,59
Date ..... ��7-
... ... ..... . . ..
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............ .................................
..... .. ..... ...... ..
has permission to perform ....
wiring in the building of ...... ...... Ael �ex- ......................
at ........ ...... POV-P/5 P-
........................................ North Andover, Mass.
'PdV
Feelf,15 c. No.
LECrRICAL INSPECI R
Check #
4%
III
E
Commonweaffl, 111ajj.chu-j,jjj
2eparinwn I O/Ji,- Ser,ice3
BOARD OF FIRE PREVENTION REGULATIONS
officiul u ---
se 0111Y
Perrnit No. 1"20
Occupancy and Fee Checked
Rev- 11/99) 0,-,e blank)
t-t-LICATION FOR PERMIT TO PERFORM ELECT
All ,vurk to be perl'ornied in accOrd011ce Nvilb 111c Massachusetts Electrical Code (IqC-C)�
V r
L113LI-RINTI INK OR TYPEALL bVrORMA770N) D
City or Town of: fior�-A fib T(
By this application [lie undersigned gives notice of bis or her'
4uniber) 7 intention to per
Location (Street & I'
Oivner or Tenant Dri, -s cc) -,AP-ke-
Oivner's Address m e-
te: —
the b
ni thv
WCAL WORK
CNIR 12.00
c/-
�fctor of I'vires:
ectTical work described beloxv.
Telephone No.
Is this perinit ill c011iulictioll with a buildin�
" I)Crllli(? Yes N [j (CheckAppropriate Bo. -o
Purpose of Buildint, Q)w'e, t ( 1, e-�
Utility Authorizalioii No.
Existin- Service ------
Amps Volts Overlicad [j Undgrd No. of �Ijetej-s
Neiv Service Amps. V 01 (s OverlicadEl Undord 0 No. of Meter
s:
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Uj
rl-\ �C, Yh rou YV) U - L�,
NO. of Recessed Fixtures
--7 —,P,CjjV,1 V1 I
Iflule "lay be 1raived by the 1,4cctor or 11"ires.
NO, Of , -
. 3
NO- Of Ceil.-Su-SP. (Piddle) Falls
Total
TrallSfOT]Ilers
No. of Lioliting Oti(le ts
--
No. of Ilut'rubs
K V,-,
Generators KVA
No. of Lightino Fi.xtures I !S7
Above
Swimming pool
�-- VA x111elgelicy
c-,riid. rnd. -E1
attM.Uni(s
NO. of Receptacle Outlets. 3D
No. of OilBurners
FIRE ALARNIS JNo-
of Zones
No. of Switches Ll C)
No. of Gas Burners
TNO. Of I Detection a a
n
Initiating, Devices
No. of Ranges
No. of Air Cond. rotal
Tons
No. of Alerting Devices
'NO. of Waste Disposers
Heat Fu ")p
j-!Nunlber.[E0iLs.__
IKW
� : �; � j;
Totals:
�etectiolii/Alertinlg Devices
No. of Dishwashers
Space/Airea Heating KW
Local El Municipal
Connection El Other
No. of Dryers
Heating, Appliances KW
Security Syst ,Is:
No. of Water
NO. of NO. 0—
I
No. of Devices or Equivalent
Helters A 'V
'Data
Signs Ballasts
-
)Viri in a:
of ,
NO Devices or Equivalent
No. Hydrolliassage Bathtubs
No. of Motors Total UP
I
I ejecommunications Wir�ng:
—..
NO. of Devices or Equivalent
OTHER:
�JP—GmcP—. S r,,o V,- 4Z)�C_kC)t- S
- -1 I'll " ... 5 "c3irea, or as required b - y the hispecior of Mi -es.
INSUP-4,NCE COVER.AGE: Unless waived by the owner, j;o permit for th�e performance of electrical . work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof ofsame to the permit issuilla office.
CHECK ONE: INIS91;U\NCE IM BONDE] OTHER El (Specify:)
Estinia ted 12lue of Electrical Work: (When required by municipal policy.) (Expiration Date)
Work to Start: hispeclions to be requested in accordance with IYIEC Rule 10, and upon completion-
cel-tifj', lin(ler thepains all d -pen allies ofpcijui-j-, that the information oil this applicatioli i's trite and co niplete.
N A [� I E: Ll C. IN 0.:
Licensee: T�icv,
(�fapplicable. enter "evenipt - in the liceirve number line.)
Address: 1-1 sccz�-s rlklte) Bus. Tel. No.:7)n I
Alt-Tel.No., '0/
I
OWNER'S INSUP�ANCE WAIVER: I am aNvar�'Ihat the License.- doesnot have the liability insurance coverage normaliv
required by laxv. By illy signature below, I hereby %vaive this TC(lillrenient- I arn tile (check one) 11 owlicr [:) ov"ller-s 14'elit.
Owner/Agent
Signature Telephone No- `RM1 T r- E- E- : S
Pj-
INSPECTION RECORD
Date
Notes Remarks
Inspector
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ....... ........... ...........
ev -rl
has -amission to perform ....... .......... e ..........................
. . i.
vnrinpan the building of ....... Z) f ... .........................................
at ....... N .... ......... orth Andover,,Mass.
Fee..CZ.O.,.(W. Lic. No./� ....... ...
LE — ICAL INSPECTOR
Check # 'of
4.3 4 0
A
a
!,.;, 7mj�__
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
�Rev. 11/99] (leaveblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code WC), 527 CMR 12.00
(PLEASE PRflff LN IAW OR 2_TPE ALL INFORMA T101\9 Date: Z, //_ e;
City or Townof: N�;ev WNPN6,-I� To the—Inspector of 07res:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) al 1) A VT --r
OwnerorTenant Telephone NOV
Owner's Address
Is this permit in conjunction with a building permit? Yes [I No J[,�n�jl (Check Appropriate Box)
Purpose of Building I Utility Authorization No.
Existing Service Amps Volts Overhead 1:1 Undgrd El No. of Meters
New Servic Amps Volts OverheadF_1 Undgrd [-] No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: . 44rk2ALL X2� 0,r -Z -
Completion ofthe followine table may be waived by the Inmector offfrimr-
No. of Recessed Fixtures
No. of Cell.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Lighting Outlets
No. of Hot Tubs
Generators KVA 7
No. of Lighting Fixtures
Swimming Pool Above Ei In-
No. of Emergency Lighting
gmd. gm d.
BattM Units
.
No. of Receptacle Outlets
No. of OR Burners
FIREALARMS
INo.ofZones
No. of Switches
No. of Gas Burners
o. of Detection and
I
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
[Tons
JKW ........
No. of Self -Contained
. Totals:
I
DetectiontAlprft Devices
No. of Dishwashers
Space/Area Heating KW
Local [I Municipal [] Other
L Connection
No. of Dryers
Heating Appliances KW
Secinity Systems:
No. of Devices or Equivalent
No. of Water
Heaters KW
No. of No. of
Data Wiring:
signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Eaulvalent
OTHER:
Attach additional detail ildesired, or as required by thekspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operatiorf' coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE e BOND F1 OTHER 0 (Specify:) 4p%r
h tLr 03
n Date)
Estimated Value of Electrical Work: j 0 , t* (When required by municipal policy.)
Work to Start: 2 - 1,2 -0 _3 Inspections to be requested in accordance with MEC Rule 10, and upon completion.
I cen*, under the pabts andpenafties ofpea'wy, the information on thir application is bw and compkie-
FHRMM NAME: 7? Yectr-i�
706 _rA) Ar CAI/ /1) LIC. NO.:
Llcensee:AM4A,P7 A - G 0 9-R-rA) _ Signatureffij,4d kZj LIC. NO.:
(Ifapphca�le, enter "exempt" in the license number line) 9- :�� -
Address: Bus. Tel. No.. -2
Tel. No.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement I am the (check one) 0 owner 0 owner's agent.
L11IR f-.0AI &"Eer- -r1JSPc-c-7-o1j 77-latespl4v ~,xw6;. oe`13-03
rlm^w-r- mva4wc,. rveelx)
Location
No. Date
TOWN OF NORTH ANDOVER
2 Aji6c;tte-of Occupancy $
Permit Fee $
�jilding/Fr&hL
01
F u , tion Permit Fee $
C
$
'10ther, Permit Fee
sewer 6onhection Fee $
Water Connection Fee $
TOTAL $
I of
�f-' Building Inspector
Div. Public Works
;11
-SMIT NO.. Y349 NORTH ANDOVER, MASS.
APPLICATION FOR PERMIT TO BUILD
L -
PAGE I
MAP 4qoll
LOT NO.
2 RECORD OF OWNERSHIP IDATE
BOOK "PAGE
Z ON EW//
SUB DIV. LOT NO.
f7--,
OCATION
PURPOSE -jA
3 -;e A!VO e 0 d
NO. OF STORIES Bak
OWNER'S ADDRESS
BASEMENT OR SLAB
ARCHITECT*S NAME
SIZE OF FLOOR TIMBERS IST 2ND 3RD
fIlGZDER-S NAME Ceo.-,f If J. '01
SPAN
DISTANCE TO NEAREST BUILDING
DIMENSIONS OF SILLS
DISTANCE FROM STREET
POSTS
DISTANCE FROM LOT LINES - SIDES REAR
GIRDERS
AREA OF LOT FRONTAGE
HEIGHT OF FOUNDATION THICKNESS
IS BUILDING NEW
SIZE OF FOOTING x
IS BUILDING ADDITION
MATER:AL OF CHIMNEY
IS BUILDING ALTERATION
IS BUILDING ON SOLID OR FILLED LAND
*-WILL BUILDING CONFORM TO REQUIREMENTS OF CODE �e-j
IS BUILDING CONNECTED TO TOWN WATER
BOARD OF APPEALS ACTION. IF ANY %J
IS BUILDING CONNECTED TO TOWN SEWER
IS BUILDING CONNECTED TO NATURAL GAS LINE
INSTRUCTIONS
SEE BOTH r..WES
PAGE I FH -L OUT SECTIONS 1 3
i
PAGE 2 FILL OUT SECTIONS 1 12
ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING
ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS
/"'PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR
ATE FILED c T,
SIGNATURR"OV-0WAER OR AUTHORIZED AGEN-P-1-
F E E —/4
PERMIT GRANTED
(ve 3 19
e- - aco
CONTR. TEL. 0 5 14"
CONTR. LIC. 0. ZZ
(L�
3 PROPERTY INFORMATION
LAND COST
-�EST. BLDG. COST 3300,
EST. BLDG. COST PER SQ. FT.
EST. BLDG. COST PER ROOM
SEPTIC PERMIT NO.
4 APPROVED BY
BOARD OF HEALTH
PLANNING BOAWD
BOARD OF SELECTMEN
WILDING IN8PEdf0—R
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POMMONWEALTH MMONWEALTH A%*M
010 CID
OF OSTON .02215
'iE MASS
MASSACHU -TTS
�p r :.'LICENSE
-111 C -,cl,NSTR. SUPERVISOR
EXPIRA.TIONI.DAT E
01 /31 /1994- ,gFFECTIVE,DATE LIC -NO.
RESTRICTIC INS
02/01/1991 055468
N OA E
GEORGE J: MAGUIRE
.4-1340 ANDOVER ST
4 02 G EO R G E TP WN-rMA,,Gl 830
5:74 601
PHOTO (BLASTING. OPR ONLY) FEE:
'D 00;
d!
�tJOT VALID UNTIL SGNE BY LICENSEE AND OFFICIALLY
HEIG,HT: STAMPED OR WNDATURE,OF, THE COMMISSIONER
DOB:
D
0411 9�1 95��
'DOCU BE, OF LICENSEE
JHIS '�ENT MUST SIGNATUAE
�S,,,,111G.T THUMB PRIll
CARRIED ON THE PERSON &
THEMOLDER WHEN ENGAG pkWISSIONER'
ED. 1. S OCCUPATION.'
TH�
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OFFICES OF:
AP13EALS
BUILDING
CONSEIWATION
HEALTH
PLANNING
Town of
NORTH ANDOVER
IAVISION OF
PLANNING & COMMUNITY DEVELOPMENT
KAREN NELSON, DIREC'I'011
120 Main Street
North Andover,
Milssil('IMSO ISO 1845
(6 17) G85-4775
In accordance witli the PrOvision-S of MGL c 40, S 54, a condition of Building Permit
Number --113 is that the debris resulting from this work shall be
disposed Tf it, a�pr�operly licensed solid waste disposal facility as defined by MGL c III, S
150A.
T'he debris will be disposed of in:
C -
(Location of Facility)
Signarture of Pcrin�I—Aipplicant
0 C -7 -
Date
S�H7-t C) t -d
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector.
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(603) 894-6465
(800) 621-1189
(603) 894-7044 FAX
January 24, 2003
Air Ouality Experts, Inc.
Asbestos Removal
40 Lowell Road, Unit I Residential-Commercial-IndustriaI
Salem, NH 03079 AirQualityExperts@AQENH.com
North Andover Health Department
146 Main Street
North Andover, MA 0 1845
JAN 3 1 2003
Dear Sir:
Enclosed please find a copy of notification sent to the state for an Asbestos
Abatement Project.
The job will take place on February 6, 2003 .
Proj ect: 27 Davis Street
Any questions concerning this matter should be directed to my attention.
Sincerely,
C�r�
Christopher Thompson
President
ri
Commonwealth of Massachusetts
SAWSbestos Notification Form ANF -001
A. Asbestos Abatement Description
INSTRUCTIONS
Contact person's title
4. Ramon Tejada, German Ziniga
1
Facility Location:
DOS Certification #
1. All sedions of this
Name of Project Monitor
form rnust be
James Driscoll
completed in order to
comply Aith
Name of Facility
7. 02/06/2003
DEP noWication
North Andover
MA
requirer'nents of 310
CMR 7. 15
City/Town
State
and the Division
8. What type of project is this?
of Occupational Safety
Worksite Location:
El Repair El Other, please specify:
(DOS) notification
9. Check abatement procedures:
requirements of 453
Basement
0 Enclosure El Disposal only
CMR 6.12
Building name, #, wing, floor, room.
2. Sub mil Original
10. Is the job being conducted: Z Indoors? El Outdoors?
Form to: 2.
Is the facility occupied? E Yes
Fj No
Common"alth of
Massachisefts
AsbestosProgram 3.
Asbestos Contractor:
PO Box 120087
Boston NA 02112-
Air Quality Experts, Inc
0087
Name
Salem
NH
Cityrrown
Zip Code
ACOOO 167
DOS License #
27 Davis Street
765207
Please Enter Decal #
No 765207
Street Address
01845 (978) 975-4419
Zip Code Telephone
40 Lowell Road, Unit One
Address
03079
Telephone
Contract Type: 0 Written El Verbal
Facility Contact Person
Contact person's title
4. Ramon Tejada, German Ziniga
AS 30223, AS32579
Name of On -Site Supervisor/Foreman
DOS Certification #
5. N/A
Name of Project Monitor
DOS Certification #
6.
Name of Asbestos Analytical Lab
DOS Certification #
7. 02/06/2003
02/06/2003
Project Start Date
End Date
7am - 3pm
Work hours Mon -Fri.
Work hours Sat -Sun.
8. What type of project is this?
0 Demolition N Renovation
El Repair El Other, please specify:
9. Check abatement procedures:
2 Glove bag [] Encapsulation
0 Enclosure El Disposal only
[I Cleanup El Other, specify:
El Full containment
10. Is the job being conducted: Z Indoors? El Outdoors?
Asbestos Notification Form ANF -001 - 9/02 Page 1
Commonwealth of Massachusetts
Asbestos- Notification Form ANF -001
765207
Please Enter Decal #
A. Asbestos Abatement Description (cont.)
11. Total amount of each type of Asbestos Containing Materials (ACM) to be removed, enclosed, or
encapsulated:
pipes or ducts (linear ft)
Boiler, breaching, duct, tank surface coatings
lin. ft
sq. ft
Corrugated or layered paper pipe insulation
Trowel/Sprayer coatings
lin. ft
sq. ft
Spray -on fireproofing
lin. ft
sq. ft
lin. ft
sq. ft
Cloths, woven fabrics
lin. ft
sq. ft
Thermal, solid core pipe insulation
sq. ft
lin. ft
sq. ft
OTHER: RISER ABOVE BOILER
/50
lin. ft
lin. ft
sq. ft
12. Describe the decontamination system(s) to
be used:
50
other surfaces (square ft)
13. Describe the containerization/disposal methods to comply with 310 CIVIR 7.15 and 453 CMR 6.14(2) (g):
Wet removal into 6 mil asbestos labeled baqs for NESHAPS reaulations.
14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
Name of DEP official
Date of Authorization
Name of DOS official
Title
Waiver #
Title
Date of Authorization Waiver #
15. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? E] Yes E No
B. Facility Description
1 - Current or prior use of facility: Residential
2. Is the facility owner -occupied residential with 4 units or less? Z Yes El No
3. James Driscoll 27 Davis Street
Facility Owner Name Address
North Andover, MA 01845
Tit—y/Town Zip Code Telephone
4. Name of Facility Owner's On -Site Manager
City/Town
Address
relephone
Asbestos Notification Form ANF -001 - 9/02 Page 2
Insulating cement
lin. ft
sq. ft
Trowel/Sprayer coatings
lin. ft
sq. ft
Transite board, wall board
lin. ft
sq. ft
OTHER:
lin. ft
sq. ft
OTHER:
- lin. ft
sq. ft
OTHER:
- lin. ft
sq. It
13. Describe the containerization/disposal methods to comply with 310 CIVIR 7.15 and 453 CMR 6.14(2) (g):
Wet removal into 6 mil asbestos labeled baqs for NESHAPS reaulations.
14. For Emergency Asbestos Operations, the DEP and DOS officials who evaluated the emergency:
Name of DEP official
Date of Authorization
Name of DOS official
Title
Waiver #
Title
Date of Authorization Waiver #
15. Do prevailing wage rates as per M.G.L. c. 149, § 26, 27 or 27A—F apply to this project? E] Yes E No
B. Facility Description
1 - Current or prior use of facility: Residential
2. Is the facility owner -occupied residential with 4 units or less? Z Yes El No
3. James Driscoll 27 Davis Street
Facility Owner Name Address
North Andover, MA 01845
Tit—y/Town Zip Code Telephone
4. Name of Facility Owner's On -Site Manager
City/Town
Address
relephone
Asbestos Notification Form ANF -001 - 9/02 Page 2
Note: Tiansfer
Stations must
comply with the
Solid VVaste
Division
Regulat , ons 310
CIVIR 19.000
Note: Contractor
must sign this form
for DOS notification
purposes
Commonwealth of Massachusetts
AsbestoS Notification Form ANF -001
B. Facility Description (cont.)
C, -
. Name of General Contractor
CityfTown
Address
zip uoae Telephone
765207
Please Enter Decal #
Contractor's Worker's Comp. Ins-urer Policy # Exp. D 3-te
6. What is the size of this facility? 3000 -2
Square Feet # of floors
C. Asbestos Transportation and Disposal
1 . Transporter of asbestos -containing material from site to temporary storage site (if necessary) to final
disposal site:
Air Quality Experts, Inc. 40 Lowell Road, Unit One
Name of transporter Address
Salem, NH 03079 (603) 894-6465
City/Town Zip Code Telephone
2. Transporter of asbestos -containing waste material from removal/temporary site to final disposal site:
Service Transport Group, Inc.
P. 0. Box 2123
Name of transporter
Address
Bristol, PA
19007
(877) 999-9559
City/Town
Zip Code
Telephone
3.
Refuse transfer station and owner
Address
City/ToNn
Zip Code
Telephone
4. BFI Imperial Landfill
Final Disposal Site location name-
Owner's Name
11 Boggs Road
Imperial
Address
City/Town
PA
15126
695-0090
State
Zip Code
.(724)
Telephone
D. Certification
The undersigned hereby states, under
Christopher Thompson
C7A
the penalties of perjury, that he/she
02�:
has read the Commonwealth of
Authorizea Signature and Date
Massachusetts regulations for the
President
Air Quality Experts, Inc.
Removal, Containment or
Position/Title
Representing
Encapsulation of Asbestos, 453 CIVIR
6.00 and 310 CIVIR 7.15, and that the
(603) 894-6465
40 Lowell Road, Unit One
information contained in this
Telephone
Address
notification is true and correct to the
Salem, NH
03079
best of his/her knowledge and belief,
City/Town
Zip Code
Fee exempt (city, Town. district, municipal housing authority, owner -occupied residential of four units or less?) 0 Yes El No
Asbestos Notification Form ANF -001 - 9/02 Page 3